Information Collection

Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits

IC 8785 under ICR 202001-0938-001 · OMB 0938-0935.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0935 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10237 Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits Form and Instruction
CMS-10237 CY 2021 Part C -Medicare Advantage and 1876 Cost Plan Ex Part C-MA and 1876 Cost Plan Expansion Application.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits	Agency IC Tracking Number:	CM-CPC

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 417.400 42 CFR 422.506 42 CFR 422.505 42 CFR 422.502 42 CFR 422.514 42 CFR 422.520 42 CFR 422.521 42 CFR 422.500 42 CFR 422.527 42 CFR 422.503 42 CFR 422.508 42 CFR 422.510 42 CFR 422.512 42 CFR 422.504 42 CFR 422.501 42 CFR 422.516 42 CFR 422.524

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10237	CY 2021 Part C -Medicare Advantage and 1876 Cost Plan Expansion Application	Part C-MA and 1876 Cost Plan Expansion Application.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 435	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	435	35	400
Annual IC Time Burden (Hours)	6,754	648	6,106
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.